Removing obstacles to childrens dental care in Medicaid: A renewed - - PowerPoint PPT Presentation

Removing obstacles to children’s dental care in Medicaid: A renewed push for change

Webinar hosted by the Children’s Dental Health Project

August 29, 2018

About the Children’s Dental Health Project

Colin Reusch, MPA Director of Policy, Children’s Dental Health Project

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Children’s Dental Health Project

In 1997, Children’s Dental Health Project was conceived to advance innovative policy solutions so no child suffers from tooth decay. We advocate for systems that nourish families…

Remove oral health as barrier to success Configure communities to support families manage their health Support those trusted in communities Champion solutions to end inequities

Why this bulletin is a big deal

A vision of what oral health care should be

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CDHP and its partners have long emphasized that:

Every child’s needs are different and there are tools to assess those needs One-size-fits-all approach to oral health care is insufficient and incompatible with Medicaid Medicaid/CHIP programs must incentivize appropriate care State are ultimately responsible for ensuring that each child gets what she needs Greater program efficiency AND better outcomes CAN be achieved together

Even with many pieces in place, the system falls short if policies aren’t aligned

Every child should get what they need to be healthy

Evidence-based clinical guidelines Risk assessment tools & guidance Statutory requirements for individualized care Minimally- invasive disease management strategies Medical/dental codes available Quality improvement requirements

• Align fee schedules, payment policies

with periodicity schedules

• Recognize periodicity schedules

establish the minimum recommended services (and State policies should not inhibit more frequent care when needed)

• Ensure that the payment policies

MCOs/payers are aligned with the periodicity schedule/priorities

• Look to existing clinical guidelines

– American Academy of Pediatric Dentistry – American Academy of Pediatrics

CMS Bulletin encourages states to…

CMS Informational Bulletin: A Tool for Change

Removing Obstacles to Children’s Dental in Medicaid: A Renewed Push for Change

August 29, 2018 Laurie J. Norris, JD

The Medicaid Children’s Dental Benefit

 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit

 Screening Services  Vision Services  Dental Services

 At intervals which meet reasonable standards of dental practice  At such other intervals as are medically necessary  At a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental health

 Hearing Services  Other services necessary to correct or ameliorate defects and physical and

mental illnesses and conditions

 Every state is required to adopt a pediatric dental periodicity schedule “after consultation with recognized dental organizations involved in child health care.”

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See Section 1905(r)(3) of the Social Security Act.

Existing Policy: Keep Kids Smiling (2013)

 Dental coverage:

 Adopt a periodicity schedule for exams and prevention  Subject to the same “medical necessity” parameters as other health care for children in Medicaid  Allow for interperiodic visits more frequent than outlined in the periodicity schedule, as medically necessary  Minimum coverage parameters: relief of pain and infections, restoration of teeth, maintenance of dental health, and medically necessary

• rthodontic services

 Available at https://www.medicaid.gov/med icaid/benefits/downloads/keep- kids-smiling.pdf

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OIG Report (2014)

 Finding: Two of four states in the study failed to align their payment policies with their periodicity schedules  Recommendation:

 Ensure that States pay for services in accordance with their periodicity schedules  Require States to conduct regular reviews of their periodicity schedules and payment policies to ensure that States are paying for services in accordance with their periodicity schedules

 Available at https://oig.hhs.gov/oei/rep

• rts/oei-02-14-00490.pdf

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CMS Response to OIG Report (2015)

“CMS concurs with this

• recommendation. CMS will work

with states to crosswalk their payment policies with their dental periodicity schedules and make any necessary adjustments to their payment policies.”

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 States should ensure that fee schedules and payment policies are aligned with periodicity schedules.

 States with dental managed care should ensure that the managed care plans’ fee schedules and payment polices align with the state’s periodicity schedule.  Payment policies for oral health services provided in primary care should also be examined for alignment with the state’s pediatric periodicity schedules.

 Available at: https://www.medicaid.gov/fe deral-policy- guidance/downloads/cib0504 18.pdf

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CMS Informational Bulletin (2018)

Aligning Dental Payment Policies and Periodicity Schedules in the Medicaid and CHIP Programs

 The periodicity schedule should be treated as a “floor” for coverage of dental services, not a “ceiling.”

 Additional services should be covered based on each individual child’s risk profile and health needs.  Allow for individualized care plans  Cover and reimburse dental care necessary to correct or ameliorate an individual child’s condition

 Even when these services fall outside of the standard scope and even when the frequency of services is greater than specified in the periodicity schedule or coverage policy.

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CMS Informational Bulletin (2018)

Aligning Dental Payment Policies and Periodicity Schedules in the Medicaid and CHIP Programs

 Implement a mechanism through which providers can obtain timely approval

• f, and payment for,

additional or more frequent dental services beyond what is specified in the periodicity schedule or coverage policy.  States delivering dental services to children through managed care or other contracting arrangements should ensure that a similar mechanism is available through their contracted plan(s).

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CMS Informational Bulletin (2018)

Aligning Dental Payment Policies and Periodicity Schedules in the Medicaid and CHIP Programs

A Role for Advocates

 Is there alignment between your state’s pediatric dental periodicity schedule and the payment policies?  Obtain and examine your state’s pediatric dental periodicity schedule, dental fee schedule, dental provider manual, dental provider advisories, etc.  Compare them for alignment on ages, frequencies, etc.  Talk to providers. Find out what they are experiencing.  Is there alignment between your state’s primary care (medical) periodicity schedule for oral health services and its payment policies?  What is the mechanism in your state to cover (and pay for) medically necessary dental and oral health services that exceed what is specified in the relevant periodicity schedule?  How has your state ensured MCO / dental plan compliance with these requirements?

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Kelly Whitener Children’s Dental Health Project August 29, 2018

Medicaid Benefits for Children and Adolescents

Medicaid’s Pediatric Benefit

Building Blocks of EPSDT

Early Identify problems early, starting at birth Periodic Check children’s health at periodic, age- appropriate intervals and as needed Screening Provide pediatrician-recommended screenings of physical, mental and developmental health Diagnostic Perform diagnostic tests to follow up when a risk is identified Treatment Treat any problems that are found

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How did we get such a comprehensive pediatric benefit in Medicaid?

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EPSDT Defined

• States must provide all coverable and medically

necessary services

• Coverable = listed in Medicaid §1905(a)
• Medically necessary = as defined by the state but see

below

• Needed to correct or ameliorate physical and

behavioral health conditions

• Determination must be made on a case-by-case basis,

taking into account a particular child’s needs

• Even if such services are not in the Medicaid state

plan

• Includes all mandatory and optional Medicaid services

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EPSDT Includes Coverage of ALL Services… whether listed as mandatory or optional

Mandatory Services

 Family planning services and supplies  Federally Qualified Health Clinics and Rural Health Clinics  Home health services  Inpatient and outpatient hospital services  Laboratory and X-Rays  Medical supplies and durable medical equipment  Non-emergency medical transportation  Nurse-midwife services  Pediatric and family nurse practitioner services  Physician services  Pregnancy-related services  Tobacco cessation counseling and pharmacotherapy for pregnant women

Optional Services

 Community supported living arrangements  Chiropractic services  Clinic services  Critical access hospital services  Dental services  Dentures  Emergency hospital services (in a hospital not meeting certain federal requirements)  Eyeglasses  State Plan Home and Community Based Services  Inpatient psychiatric services for individuals under age 21  Intermediate care facility services for individuals with intellectual disabilities  Optometry services  Other diagnostic, screening, preventive and rehabilitative services  Other licensed practitioners’ services  Physical therapy services  Prescribed drugs  Primary care case management services  Private duty nursing services  Program of All-Inclusive Care for the Elderly (PACE) services  Prosthetic devices  Respiratory care for ventilator dependent individuals  Speech, hearing and language disorder services  Targeted case management  Tuberculosis-related services

See Social Security Act § 1905(a)

EPSDT - Limitations

Cost Effective Alternatives Utilization Controls Experimental Treatment

Permitted Prohibited

 Utilization controls, such as prior authorization for some services × Prior authorization for screenings × Using utilization controls that delay the provision of necessary treatment × Service caps (“Hard limits”)  While EPSDT does not require coverage of experimental services, a state may do so if it determines that treatment would address a child’s condition  Relying on the latest scientific evidence to inform coverage decisions  Considering cost when deciding to cover a medically necessary treatment or an alternative  Covering services in a cost effective way, permitted they are as good as or better than the alternative × Denying treatment due to cost alone

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Promoting EPSDT through Partnerships

Marielle Kress Director, Federal Advocacy American Academy of Pediatrics

STAY IN THE BOAT

AAP/CCF PROJECT GOALS

Protect and strengthen children’s Medicaid benefits under EPSDT at the federal and state levels by:

Educating and raising awareness among policymakers and other stakeholders about EPSDT and its critical role for children Strengthening the capacity for collaborative initiatives between state child advocates and AAP chapters (including technical assistance with 6 states) Identifying and executing state-level strategies to strengthen EPSDT protections for children enrolled in Medicaid

• Hosted a legislative

day in February, using a new EPSDT fact sheet

• Creating a data

dashboard focusing

• n the collection of

quality measures

• Updating EPSDT

section of health plan manual

ARIZONA

Three-Pronged Approach:

• Providers: Editing

EPSDT brochure for

• ffices
• Beneficiaries: Adding

EPSDT benefits to CHIP program

• Policymakers: Hosted

a legislative breakfast and meeting with gubernatorial candidates

IOWA

GEORGIA

• Identifying

administrative procedures to help increase coverage (ELE and 12- month continuous)

• Hosted health care

access roundtable focused on transportation barriers

• Exploring idea of

folding separate CHIP into Medicaid

• Building relationships

with MCOs & influence new MCO contracts

NORTH CAROLINA

UTAH

• Meeting with EPSDT

staff and considering push to add EPSDT to CHIP

• “Listening Tour” of

providers

• Advocacy day in

November

• Tiny Hearts advocacy

day in Feb, still using resources to educate providers and lawmakers about EPSDT

WEST VIRGINIA

NEW AAP STATE EPSDT PROFILES

• New! AAP State EPSDT

Profiles

• https://www.aap.org/en-

us/advocacy-and-policy/federal- advocacy/Pages/Childrens-Health- Care-Coverage-Fact-Sheets.aspx

EPSDT EDUCATION FOR

PROVIDERS AND ADVOCATES

HTTPS://CCF.GEORGETOWN.EDU/2018/

07/20/EPSDT-EDUCATION-FOR-

PROVIDERS-AND-ADVOCATES/

SAVE THE DATE

WEBINAR: MEDICAL NECESSITY AND BEST PRACTICES FOR ENSURING CHILDREN ENROLLED IN MEDICAID CAN ACCESS NEEDED SERVICES THURSDAY, SEPTEMBER 20TH 1 PM – 2:30 PM EASTERN

Opportunities for progress in your state

Strategies and tools for effective advocacy

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Colin Reusch, MPA Director of Policy, Children’s Dental Health Project

Stakeholders impacted by CMS bulletin

• State Medicaid and CHIP

programs

• Payers (Insurers, Managed

Care Organizations [MCOs], Dental Contractors, etc.)

• Dental/Health Care Providers
• Families/Caregivers of Children

covered by Medicaid and CHIP

Unaware of the bulletin and its implications Focused on specific

• bstacles to

individualized care Constrained by existing care models and costs May believe they are already sufficiently in compliance

Stakeholders may not act independently

Unaware of the bulletin and it’s implications Focused on specific

• bstacles to

individualized care Constrained by existing care models and costs May believe they are already sufficiently in compliance

Stakeholders may not act independently

So advocacy efforts should begin by investigating stakeholder concerns and efforts

Questions to guide your efforts…

State Medicaid/CHIP Program Administrators

• Review your state policies (Medicaid fee

schedule, dental periodicity schedule, provider manual, etc.) for alignment

• Ask your Medicaid/CHIP Dental

Director…

• How has the CMS bulletin been

communicated to providers and plans/contractors?

• Are policies and procedures clearly

articulated in state/plan documents (e.g., provider manual)?

• What do contracts with payers require?
• How does state verify children are getting

appropriate care (quality strategies, auditing/oversight, etc.)?

• Is risk assessment covered and how

does it impact care/payment?

Payers (Insurers, Managed Care Organizations [MCOs], Dental Contractors, etc.)

• “Payers” play a powerful role in sharing information

and incentivizing care protocols

• Ask the MCOs or plans in your state program:
• Have plans and contractors reviewed their own

policies and procedures for alignment?

• How might their payment policies clash with

principles of EPSDT, especially for high-risk kids?

• Have they communicated the contents of this

bulletin with providers on their panels?

• How do they evaluate whether appropriate care is

being provided to children (i.e. medical necessity & prior authorization policies, internal tracking and auditing measures)?

Providers (and Professional Organizations)

• Providers are where the rubber meets the

road and must have a clear understanding

• f Medicaid/CHIP policies
• Policy alignment may be aided by

working with professional

• rganizations:
• How has the CMS bulletin been

communicated to participating providers?

• Have providers in your state

encountered barriers to providing appropriate oral health care? Can members identify specific issues, procedures, or policies that require attention?

• How easy is it for providers to interpret

such policies as outlined in provider manuals and other communications? (Does a lack of clarity disincentivize care)?

Families, Caregivers, and Patients

• Assess the knowledge of families covered by

Medicaid or CHIP:

• Do parents know their children are entitled to

individualized care to treat oral health issues as well as mitigate any worsening disease?

• Do they know what to ask for if their child is at high

risk for tooth decay?

• What materials and communications are publicly

available to families?

• Do they communicate to families how to access care

in different settings (dentists office, pediatrician

• ffice, etc.)?
• Do families know what services can be made

available to them (e.g., more frequent follow-up for high-risk patients)?

Medicaid/CHIP Agencies

• Alignment of Periodicity

Schedules & Payment Policies

• Oversight of payers &

contractors

• Clear contract language
• Quality/performance

improvement strategies

• Provider manuals & outreach
• Risk assessment policies

Payers (MCOs, dental plans, etc.)

• Aligning payment with state

policies

• Clear communication with

providers

• Easy-to-navigate prior

authorization procedures

• Internal auditing
• Patient outreach

Providers & Professional Orgs

• Communications with

members

• Understanding of state &

payer policies

• Identification of existing

barriers

• Patient education

Patients/Families

• Communication from

Medicaid agencies, payers, and providers

• Understanding of coverage,

benefits, limits, etc.

• Understanding of

individualized care & risk factors

Children receive care based on their needs without unnecessary delay

A few parting thoughts…

• Just because it’s in the periodicity schedule or fee

schedule doesn’t mean kids are getting the care they need

• Service frequency and prior authorization policies may

become real barriers to necessary care

• Incentives for appropriate care don’t always have to be

financial

• State Medicaid/CHIP agencies are ultimately

responsible for ensuring contractors & their policies don’t conflict with EPSDT or state CHIP requirements

Resources

• CDHP Quick Guide on CMS Informational Bulletin
• AAPD Guide to State Periodicity Schedules
• ADA Medicaid Provider Reference Guide
• MSDA National Profile of State Medicaid & CHIP

Oral Health Programs

• CMS Briefs on Strategies for Reducing Early

Childhood Tooth Decay

• CMS Insure Kids Now (Medicaid/CHIP Benefit Info)
• CDHP Fact Sheet on Oral Health Risk Assessment

Thank you!

For more information:

Follow us on Facebook or Twitter:

Web: www.cdhp.org Twitter: @Teeth_Matter

Colin Reusch

Director of Policy Email: creusch@cdhp.org Phone: 202.417.3595

Questions & Answers

Type your question in to the chat box.

Contacts for further questions: Colin Reusch, Children’s Dental Health Project Director of Policy Email: creusch@cdhp.org Phone: 202.417.3595 Amy Cotton, Children’s Dental Health Project Policy Communications Manager Email: acotton@cdhp.org Phone: 202.417.3602

Thank you for joining us!